| Organization Name: | PELHAM SUPPORTIVE SERVICES |
| NPI Number: | 1053626135 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | MILDRED WILSON (OWNER) |
| Mailing Address: | 2226 Memory St Fayetteville |
| State: | NC US |
| Postal Code: | 283045827 |
| Phone Number: | 9104290081 |
| Fax Number: | 9108849806 |
| NPI Enumeration Date: | 08/12/2010 |
| NPI Last Update Date: | 08/12/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 320800000X |
| License Number: | MHL-2620 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NC |
| Taxonomy Type: | Residential Treatment Facilities |
| Taxonomy Classification: | Community Based Residential Treatment Facility, Mental Illness |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A home-like residential facility providing psychiatric treatment and psycho/social rehabilitative services to individuals diagnosed with mental illness. |